Products Changing Tier Status

Products Changing Tier Status
Key: Lowercase print = generic; UPPERCASE PRINT = BRAND;
PAR = Prior Authorization Required; EPA/ST = Enhanced Prior Authorization/Step Therapy Required;
QLL = Quantity Level Limits Apply
The information below shows brand medications that are changing tier status. Generally, the lower the
tier numbers, the lower the cost for members. In many cases, drugs are moved to higher tiers because
generic equivalents or more cost-effective alternatives are available on lower tiers.
The following medication is changing tier status effective January 1, 2013.
For Commercial Members:
• Tier 2 to Tier 3 – TESTIM (Impacted members will be notified prior to change.)
• Tier 3 to Tier 2 – AXIRON, BYSTOLIC (EPA), DEXILANT (EPA, QLL), WELCHOL
For Medicare Members:
• Tier 4 to Tier 3 (Non-Preferred/Non-Formulary Brand to Preferred/Formulary Brand) AZOR (ST), BENICAR/-HCT (QLL), EXFORGE/-HCT (ST), PRADAXA (PAR), SIMCOR
(ST, QLL), TRIBENZOR,WELCHOL
• Tier 3 to Tier 4 (Preferred/Formulary Brand to Non-Preferred/Non-Formulary Brand) COMTAN, CRESTOR (ST, QLL), DIOVAN/ - HCT (ST,QLL), GEODON (QLL),
MENEST (PAR), NUVIGIL (PAR), ONGLYZA (ST), PLAVIX, SEROQUEL, SINGULAIR
(ST), SURMONTIL, TEKTURNA/-HCT (ST), VIRAMUNE, VYTORIN (ST, QLL),
ZYPREXA/- ZYDIS (QLL)
• Tier 5/NF to Tier 5 – (Non High Cost to High Cost) – fondaparinux (QLL), PROVIGIL
(PAR, QLL), XGEVA (PAR)
• Tier 5 to Tier 5/NF (High Cost to High Cost/ Non-Formulary) - ABSTRAL (ST, QLL),
ARIXTRA (QLL), REVATIO (PAR), TYSABRI (PAR)
• Not Covered - butalbital/acetaminophen/caffeine (e.g. FIORICET), diazepam rectal get
e.g., DIASTAT), MEBARA
The information contained in this document is current at the time of printing, is not all
encompassing and is subject to change.